Norway’s ‘Global Business Plan’ will put countries in control of reaching the Millennium Development Goals – but funding will depend on success measured by ‘evaluation research’. On 26 September 2007 Jens Stoltenberg, Prime Minister of Norway, announced plans for a radical transformation of international development funding, with a ‘Global Campaign for the Health MDGs’. Developing countries will prepare their own national plans to achieve Millennium Development Goals 4, 5 and 6 to reduce child and maternal mortality, and combat AIDS and other diseases, while donors will relate their support to the countries’ plans; and support will depend on measured results. The Campaign could be extended to the whole of health, and even development, and become each country’s truly Global Business Plan. We talk to the plan’s principal architect, Tore Godal.
For years there’s a drought – and then suddenly it pours. The world seems, all of a sudden, to be awash with plans for radical improvements to the funding and management of world health, and all of these put countries back in charge of their national health programmes. This should offer a great new opportunity to developing country ministries of health – if they can see the wood for the trees amongst the various proposals.
READ ON: Norway’s Prime Minister Jens Stoltenberg’s speech to the UNGA (196 kb pdf)
To clarify the situation, and reveal the opportunities, perhaps it’s best to go back to the beginning.
History will tell the source and gestation of these ideas, which is certainly lengthy and complex, but for the moment many indications point to one country – Norway.
READ ON: Global Campaign for Health MDGs: Jens Stoltenberg launched his campaign for MDGs 4 and 5 at the Clinton Global initiative and the UN General assembly, in New York, on 26 September 2007, committing US$1 billion over 10 years, ‘to save women and children’. Norway’s press release
Norway’s concept paper for a ‘Global Business Plan’ for health was widely circulated early in 2007, underlies the Global Campaign for the Health MDGs launched by Prime Minister Jens Stoltenberg in New York on 26 September. No doubt it also informed the launch of the International Health Partnership in London on 5 September.
In the Norwegian paper its principle architect Tore Godal – leprologist and past director of the Special Programme for Research and Training in Tropical Diseases (TDR) and founder-director of the Global Alliance for Vaccines and Immunization (GAVI), clearly explains its motivation and principles.
The challenge is blindingly obvious: one child dies every three seconds and a woman in labour every minute. And yet the UN Millennium Development Goals 4 and 5 to reduce these tolls are far from being reached by their target date of 2015. (The same of course is true for the other health related goal, MDG 6, for reducing the burden of AIDS and other diseases; this was added later to the Global Campaign for the Health MDGs and to the International Health Partnership.)
READ ON: Global Campaign for MDGs 4, 5 and 6 (676 kb pdf)
However, says the concept paper, despite the challenge there’s hope: “Many countries, among them low-income countries, demonstrate that political leadership, good management, adequate health services and community commitment progress can be achieved with modest means”.
So how’s it done? Good national and local management, and honest reporting of results are fundamental. But the donors on whom poor countries still depend are still divided, each arriving with their own politics, programmes, goals and methods, each demanding to be serviced in its own way.
As the paper says: “In the rapidly expanding field of global health, most of the billions of dollars available today are targeted for specific purposes: antiretroviral therapy for AIDS, vaccinating children, supplying bed nets, and so forth. As laudable as these efforts are, women, newborns and children need more: to stay alive, healthy and well they need to have access to essential health services in the communities where they live”.
“This is what the Global Business Plan aims to do” says the paper. “Through output-based financing it will promote the channelling of funds through existing mechanisms to support the delivery of essential health services, rather than earmark support for specific interventions….
“The Global Business Plan will propose that low-income countries move rapidly towards submitting one proposal, their national health plan, to a consolidated group of bilateral and multilateral funders for review, rather than separate proposals to each potential source of funding….
Furthermore, “in order to be effective, the delivery of health services needs to be built on firm evidence,” says the paper. However, “instead of waiting until all the evidence is available, the Global Business Plan will take a ‘learning by doing’ approach. Evaluation research will be supported in order to generate and share valuable knowledge about what works and what does not…”.
“Political momentum will be mobilised through the Network of Global Leaders… Engaging with civil society and building local advocacy skills will be instrumental to accelerating progress…”.
If this sounds very like UK Prime Minister Gordon Brown’s and German Chancellor Angela Merckel’s International Health Partnership launched later in the year in London, on 6 September, the similarity is no doubt not coincidental.
READ ON: UK Prime Minister Gordon Brown and German Chancellor Angela Merckel’s announcement of the IHP after the G8 meeting in Heiligendamm
It seems that this creative plan, originating in Norway, is taking rapid hold among the world’s leaders. Which is good for development, if countries can find their way through the thicket of new proposals.
RealHealthNews spoke to Tore Godal about the original Norwegian plan at the Global Health Council in Washington this May.
>RHN: Could you briefly describe the fundamentals of the Global Business Plan?
TG: If you look at the ‘flower’ diagram [ see below and click for a larger version ], you see that we are putting the national health systems at the centre, and everything around it is international.
The two crucial things are that financing should be based on performance, for example the US$20 for each additional child immunised provided by GAVI – and that there should be an independent assessment of both the proposals as well as progress. And these two are key.
We are also suggesting that we can bring these principles down to the country – it would be the same elements that you’d need, but now between central government and the operational level and local community.
READ ON: Global alliance for Vaccines and Immunisation (GAVI) – US$ 20 per additional child immunised
>RHN: Why do you think these things are possible now? Are things improving at country level in some way? Do you think capacity for this kind of planning is increasing?
TG: Yes. The question of clarity, in terms of what is needed at country level, is absolutely important. Then we can talk about ‘performance financing’ at the country level. We de-link financing from targets tied to that particular financing, but then we have the validation of reported results.
We know by discussion with the Global Fund to Fight AIDS, Tuberculosis and Malaria, for example, that they are prepared to put their money into such a national plan – not to earmark it for specific activities but into a national health plan.
And we believe that there are a number of different funders that would prepared to finance against one plan, provided that there is an independent review of that plan, or ‘due diligence’ to determine that the plan meets specifications.
>RHN: This independent review would be an international review presumably?
TG: It could be at a national level. And then the UN and the World Bank would have very important functions in relation to enabling and capacity building for the government actually to manage this properly.
In this way we are using MDGs 4 and 5 to help consolidate the national architecture and to get away from the fragmentation of aid.
>RHN: You are saying that this could be moved up to the other MDGs and to other health issues?
>RHN: So this is a leader?
TG: It’s a leader and it’s a concept. The movements and interest groups that want some specific issue to be addressed, they will continue – that we must anticipate.
>RHN: And they have their benefits.
TG: Yes. But this system can actually absorb any special interest, new or old, in a way that you don’t need to target the funding towards the special interest, provided there is an indicator at a local level that can be used to measure performance.
>RHN: So that’s the principle, but how will it move forward? Obviously some countries are more prepared and ready to do this kind of thing than others. Do you see there being some lead countries where this will fit in?
TG: We are talking about a step one where there will be lead countries that would do this, because we need a bottom-up approach. We really need to test it out at the country level.
>RHN: Do you have any particular countries in mind?
TG: We are working with Tanzania and Pakistan, for example, as two pilot countries for this. There will be a number of pilot countries. And we are discussing with the Global Fund what the requirements would be for them to join in such an effort.
>RHN: In Tanzania and Pakistan?
TG: Or elsewhere, we haven’t discussed specific countries yet with them, but that becomes a pragmatic practical proposition of terms of what we then need to have at the country level for them to de-link their resources.
>RHN: So what sort of time scale are we talking about in setting this up?
TG: Well, we are always moving fast. That’s enough! We hope that we certainly will be ready before the end of the year, but it could be just one country with plans ready for support.
>RHN: We’re speaking here at the Global Health Council meeting in Washington, and we heard UNICEF describing the tangle of donors and programmes, and constant variation in budgets faced by health ministries. This kind of plan would help, at least with MDGs 4 and 5, to integrate those and create a more stable environment.
TG: Yes, absolutely.
>RHN: Do you agree with Francisco Songane, the ex-minister of health in Mozambique [see interview in this issue of RealHealthNews], that individual programmes like PEPFAR (the US President’s Emergency Plan for AIDS Relief) can be destructive in certain ways, for example by drawing in too many local staff?
TG: I take his point. Obviously there can be distortions that must be a challenge to the health system. But now there is a lot of momentum growing to actually allow more flexibility for those kind of dedicated funds. There is a call for a change in mentality, and that change in mentality is under way.
>RHN: So you would hope to see that in PEPFAR too, for example?
TG: Absolutely, and I think that and there are smart people thinking about exactly this performance-based approach, and how can we do that in a way that it will satisfy PEPFAR but still give more flexible resources at operational level.
>RHN: Do you think that’s been taken on board by the US Child Survival Initiative, for example? Here in Washington that still sounded a little bit top down.
TG: Well, the US have restrictions in terms of exactly how they can use their funds, but they are clearly also recognising that it is very important to increase their flexibility for using resources.
>RHN: One last question. Norway is a highly respected country, but it’s a small country. How has it actually got the power to make these things change? Simply through persuasion and intelligence? How is it working?
TG: We have the extraordinary situation that we have a Prime Minister, Jens Stoltenberg, that has a commitment from his heart, so to speak, to do something – and the opportunities that that gives are quite amazing, if you can grasp them.
For example he met here in Washington with President Michelle Bachelet from Chile, a paediatrician, and then he asked her to join in his network of global leaders. Every time there is a visitor of that calibre to Norway, or he visits them, he will do that and in that way bring up commitment at the highest political level in the world. So you have great opportunities when you have a leader that has such a special commitment.
>RHN: Dr Godal, how did you get the ear of the Prime Minister? Your advice has obviously been very significant in developing both this, and other programmes, such as TDR and the Global Alliance for Vaccines and Immunisation (GAVI) – which of course you directed.
TG: Well he got interested in vaccination, and we travelled and started to work together around vaccination. And then he invited me to apply for a job as Special Advisor on Maternal and Child Health in his office, once he was the Prime Minister.
>RHN: Does that interest come from any personal experience of his?
TG: Yes. Vaccination was very important to him. He is amazed that by just putting a few polio drops in the mouth of a child, that child can be protected for the rest of her or his life. The biology of that, of course, is extraordinary.
But he’s also a brilliant economist, and he says that ‘vaccination matters to me three reasons. One, I know how important it is that children are healthy. Two, as an economist I can understand how cost effective vaccination is. And three, as a politician I can do something about it.’
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